Submit Case for Evaluation

Worker's Compensation Form

Using a form is helpful, but not required. You can always contact us or call us at 207-780-6700 or toll free at 800-425-6700.

Name

First Name

Last Name

Email Address

Phone

(###)

###

####

Please briefly describe the circumstances surrounding your injury

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Age

Social Security Number

Date of Injury

YYYY

Nature of Injury

How were you referred?

Employer

Date of HIre

YYYY

Did you work for more than one employer at the time of your injury?

Yes

Names of Worker's Compensation Insurer

How much did you earn, per week, before taxes, at the time of your injury?

Did you lose time from work because of your injury?

Yes

Are you currently receiving weekly compensation?

Yes

If yes, how much are you currently receiving per week?

Has the workers' compensation carrier paid all of your medical bills?

Yes

Please list the names of the doctors who have treated you for your injury